Decoding white coat hypertension.

There is arguably no less understood or more intriguing problem in hypertension that the "white coat" condition, the standard concept of which is significantly blood pressure reading obtained by medical personnel of authoritative standing than that obtained by more junior and less authoritative personnel and by the patients themselves. Using hospital-initiated ambulatory blood pressure monitoring, the while effect manifests as initial and ending pressure elevations, and, in treated patients, a low daytime profile. The effect is essentially systolic. Pure diastolic white coat hypertension appears to be exceedingly rare. On the basis of the studies, we believe that the white coat phenomenon is a common, periodic, neuro-endocrine reflex conditioned by anticipation of having the blood pressure taken and the fear of what this measurement may indicate concerning future illness. It does not change with time, or with prolonged association with the physician, particularly with advancing years, it may be superimposed upon essential hypertension, and in patients receiving hypertensive medication, blunting of the nighttime dip, which occurs in about half the patients, may be a compensatory mechanisms, rather than an indication of cardiovascular risk. Rather than the blunted dip, the morning surge or the widened pulse pressure, cardiovascular risk appears to be related to elevation of the average night time pressure.

Extreme Hyperpyrexia of Uncertain Origin.

BACKGROUND: The definition of hyperpyrexia is currently limited to temperatures reaching 106.7°F. A wide range of etiologies have been identified in the literature for an insidious onset of hyperpryexia, however a rapid ascent higher than temperatures of 106.7°F has never been reported nor evaluated. We present the case of a young paraplegic who developed an extreme hyperpyrexia, which to our knowledge is the highest occurring temperature reported in contemporary medical literature. He had a number of medical conditions, none of which are known to produce fever. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Fever, although a common presentation in the ER in the presence of various symptoms and comorbidities can obscure the diagnosis and lead to unwarranted evaluations. As such this patients case identifies a diagnosis of a fatal ascension of fever.

Relation between achieved heart rate and outcomes in patients with atrial fibrillation (from the Atrial Fibrillation Follow-up Investigation of Rhythm Management [AFFIRM] Study).

Many patients with atrial fibrillation (AF) are treated with rate control and anticoagulation. However, the relation between the degree of heart rate (HR) control and clinical outcome is uncertain. We assessed whether lower achieved HR at rest and/or lower achieved exercise HR was associated with improved prognosis, quality of life (QoL), and functional status among patients in the AFFIRM study. Patients in the rate control arm and who were in AF at baseline and 2 months were included. Patients were grouped by quartile of achieved HR at rest (44 to 69, 70 to 78, 79 to 87, 88 to 148 beats/min) and achieved exercise HR following a 6-minute walk (53 to 82, 83 to 92, 93 to 106, 107 to 220 beats/min). QoL measurements and functional status were also analyzed. Complete data were available for 680 patients for achieved HR at rest, 349 patients for achieved exercise HR, and 118 patients for QoL. Survival free from cardiac hospitalization and overall survival were not significantly different among quartiles of achieved HR at rest (p = 0.19 and p = 0.8, respectively) or achieved exercise HR (p = 0.77 and p = 0.14, respectively). After controlling for covariates, there remained no significant relation between either achieved HR at rest or achieved exercise HR and event-free survival (hazard ratio 0.95, p = 0.35 and hazard ratio 0.98, p = 0.81) or overall survival (hazard ratio 1.03, p = 0.70 and hazard ratio 1.22, p = 0.13). Furthermore, there was no significant association between achieved HR and QoL measurements, New York Heart Association functional class, or 6-minute walking distance. After 2 months of drug titration, neither achieved HR at rest nor achieved exercise HR predicted survival free from cardiovascular hospitalization, overall survival, QoL, or functional status among patients with AF.

Spectral Turbulence Analysis: A Valuable Method for the Prediction of Cardiac Events in Elderly Patients With Intraventricular Conduction Abnormalities.

BACKGROUND: Intraventricular block and its associated heart disease are common in the elderly. The aim of this study was to evaluate the ability of spectral turbulence analysis of signal-averaged electrocardiograms to predict the cardiac events of sudden death, sustained ventricular tachycardia, ventricular fibrillation, and syncope in elderly patients with wide QRS as seen on a standard 12 lead surface electrocardiogram. METHODS: We studied 51 consecutive elderly patients (age at or above 70 years), for whom at least 12 months of follow up was available following the initial signal-averaged electrocardiogram. The patients included 40 males, and 11 females, of whom 47 had coronary artery heart disease and 25 had a history of prior myocardial infarction, and 4 with dilated cardiomyopathy. The subjects were divided into 3 groups. Group I comprised 22 patients without any events; Group II included 16 patients with events-sudden death(N equals 6), ventricular tachycardia (N equals 5), ventircular fibrillation (N equals 1), and syncope (N equals 4); Group III consisted of 13 patients with nonsustained VT. The bipolar three-lead orthogonal signal-averaged electrocardiogram from each patient was analyzed for spectral turbulence. The optimal criteria for predicting cardiac events were determined by computer algorithm. RESULTS: Spectral turbulence predicted future cardiac events with a sensitivity of 88%, a specificity of 67%, a positive predictive accuracy of 67%, a negative predictive accuracy of 88%, and a total predictive accuracy of 74%. CONCLUSIONS: Spectral turbulence analysis of the signal-averaged electrocardiogram was found to be a highly sensitive predictor of serious cardiac events in elderly patients with a wide QRS complex.